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A Learning Collaborative for Health Center Decision Makers and Providers to Increase Capacity for Prescribing Medications to Treat Opioid Use

State: IL Type: Promising Practice Year: 2019

The Chicago Department of Public Health (CDPH) has a vision of a city of thriving communities where all residents are able to live healthy lives. The City of Chicago is located in Illinois on the western shore of Lake Michigan. It is home to nearly 3 million people across 234 square miles. Demographically, Chicago's population is roughly one-third White, one-third Black/African-American, and one-third Hispanic/Latinx. Almost one-quarter of Chicagoans live below the poverty line. 

Overdose deaths involving opioids rose from 426 in 2015 to 741 in 2016, an increase of 74%. Those dying from opioid-related overdose deaths are more likely to be men, 45-64 years old and Black/African American. The rate of overdose deaths involving heroin was higher than the rate of deaths involving other types of opioids. One factor in preventing future opioid-related overdose deaths is providing evidence-based treatment for opioid use disorder. Like many other chronic conditions, people often need life-long support to be able to effectively manage opioid use disorder. 

Buprenorphine and methadone are highly effective medications for treatment of opioid use disorder. Increased access to these medications has been shown to significantly reduce opioid-related mortality.  Access and uptake remain limited nationwide, with only one-third of treatment plans for opioid use disorder including medications.  Unlike methadone, buprenorphine can be prescribed in a medical office by any medical provider with a waiver under the Drug Addiction Treatment Act of 2000 (DATA 2000). Therefore, there are more opportunities to expand access to buprenorphine. CDPH has prioritized increasing access to buprenorphine to address the increasing overdose deaths due to opioids in Chicago.

After assessing interest, CDPH hosted a learning collaborative (LC) among the federally qualified health centers (FQHCs) and other interested health systems in the City of Chicago.  The goal was to increase access and capacity for buprenorphine in office-based settings, by facilitating conversation and knowledge sharing, providing access to addiction treatment experts, assisting in incorporation of evidence-based practice, and supporting efficient training.  Unlike many existing education and technical assistance programs, this LC included a specific decision-maker track that focused on a novel participant-driven approach to helping health system leadership build systems to support staff and implement system-wide best practices. 

The decision-maker track consisted of quarterly, half-day in-person meetings from July 2017—June 2018. Decision-maker sessions combined participant presentations and group discussions. Topics were selected from surveys of participants, creating an evolving, participant-driven process.  

In spring 2017, health systems shared information about baseline service capacity, including number of prescribers with a DATA waiver, number of providers actively prescribing, number of patients on buprenorphine, and presence of various workflows and protocols.  The same systems-level metrics were again collected at the final decision-maker session (spring 2018). After each session, individual participants completed online evaluations of session format and presentations. The final evaluation included in-depth questions about the overall utility of the LC.

Fifteen separate health systems participated in the LC decision-maker track. There were 38 unique participants with an average of 21 attendees per decision-maker track session.  

Health systems-level metrics were compared pre- and post-LC from the 11 health systems that participated for the entire year. Two health systems had not begun prescribing buprenorphine when the LC concluded. All other clinics showed increases in the number of providers actively prescribing buprenorphine, the number of active patients receiving buprenorphine, and the number of locations prescribing buprenorphine. In total, across all 11 health systems, there was a 52% increase in the number of prescribers with DATA waivers (from 79 to 120), an 84% increase in the number of providers prescribing buprenorphine (25 to 46), and a 68% increase in the number of locations prescribing buprenorphine (25 to 42).  

Sixteen decision-makers (42% of decision-makers) completed the final post-decision-maker LC track evaluation. These respondents strongly agreed (3.9 on 4-point scale) that their organization benefited from their attendance. Every respondent agreed or strongly agreed that the collaborative impacted their work and they would return if the collaborative were continued. Additionally, the surveys after each meeting indicated that each meetings objectives as well as overall objectives were met. 

Given that some health systems had already committed to expanding buprenorphine access as a part of a separate grant, it is possible that the combination of established buy-in and financial support coupled with our quarterly meetings and support contributed to the success. Additionally, the participant-driven nature of the LC may have contributed to its success, in that attendees could bring up actual issues and leave with possible solutions, having heard from colleagues direct experiences with the same issues. 

https://www.cityofchicago.org/city/en/depts/cdph.html

The City of Chicago has experienced a dramatic increase in overdose deaths involving opioids in the past two years. There was a 74% increase from 2015 to 2016 (from 426 overdose deaths involving opioids to 741 in 2016). In 2017, there were almost 800, equating to a rate of 29.1 per 100,000 population.  For context, this is more than the number of people who died from either gun-related homicide or traffic crashes in Chicago in the same year. Most overdoses are not fatal; the Chicago Fire Department's emergency medical services team responded to 7,526 opioid-related overdoses in Chicago in 2017 – an average of 21 responses per day.

In 2017 in Chicago, opioid-related overdose death rates remained highest among men; non-Hispanic blacks/African Americans; middle aged adults (45-64 years); and persons living in communities experiencing high economic hardship. Chicago residents who died from an opioid-related overdose in 2017 lived across the city. Ninety-four percent of Chicago's community areas were home to at least one resident with a fatal opioid-related overdose. Residents who died from an opioid overdose were more likely to live in communities experiencing high economic hardship (48%) than in communities experiencing medium (25%) or low (27%) economic hardship. In Chicago, illicit opioid use (heroin, fentanyl) is linked to more than 90% of fatal overdoses; deaths linked to prescription opioid pain relievers are much less common. Chicago has seen a dramatic increase in overdose deaths involving fentanyl; the rate of overdose deaths involving fentanyl increased by 533% from 2015 to 2017. Fewer than 3% of Chicago adults reported prescription opioid pain reliever misuse (2.8% in 2017). However, 15% of high school students in Chicago in 2017 reported prescription opioid pain reliever misuse, consistent with the national rate of 14% among high school students. In contrast, high school students in Chicago in 2017 were significantly more likely to report heroin use than high school students nationally (4.9% compared to 1.7%).

In response to this public health problem, the Chicago Department of Public Health (CDPH) has prioritized increasing access to buprenorphine to address the situation. Buprenorphine is a highly effective medication for treatment of opioid use disorder. Increased access to buprenorphine has been shown to significantly reduce opioid-related mortality, yet access remains limited, with approximately one-third of treatment plans for opioid use disorder including any medication for opioid use disorder. Unlike methadone, buprenorphine can be prescribed and dispensed in a medical office by any medical provider who has a waiver under the Drug Addiction Treatment Act of 200 (DATA 200). Therefore, more opportunities exist to expand access to buprenorphine.

In November 2016, the online Substance Abuse and Mental Health Services Administration (SAMHSA) treatment finder listed 152 physicians in Chicago as buprenorphine prescribers. When CDPH attempted to confirm this information with the providers, 60% (n=91) could be reached, and only 45% of those reached (n=41) were currently prescribing the medication. Nationally, there are similar low prescribing rates among providers with DATA waivers. The following are identified barriers to prescribing buprenorphine: insufficient training, poor care coordination, lack of reimbursement, and low institutional support. 

As of spring 2017, multiple Federally Qualified Health Centers (FQHCs) in Chicago received a Health Resources and Services Administration award for buprenorphine expansion. The Chicago Department of Public Health wanted to support this expansion, in light of the identified barriers. After assessing interest, CDPH hosted a learning collaborative (LC) among the funded FQHCs and other interested health systems in the City of Chicago.  This LC's aim was to facilitate conversation and knowledge sharing, provide access to addiction treatment experts, assist in incorporation of evidence-based practice, and support efficient training. 

Unlike many existing education and technical assistance programs, this LC included a specific decision-maker track that focused on a novel approach to helping health system leadership build systems to support staff and implement system-wide best practices, in addition to training prescribers and front-line staff. Existing literature and CDPH's survey described above indicate that just getting a waiver does not necessarily lead to prescribing buprenorphine for opioid use disorder. Many barriers are systematic, and thus should be addressed at a system-level, not just a provider-level. The idea of a LC in general is not innovative, but utilizing one to impact systems-level change across multiple health systems to increase access to an evidence-based treatment for opioid use disorder is.

Each meeting of the LC was focused on a different topic. Each discussion was based around evidence-based and promising practices in each topic (ie- for screening, various validated screening tools were presented, for opioid use disorder and pain, CDC's guidelines were presented, etc.). The originality was the discussions around these evidence-based practices and how to practically and logistically apply them to each unique setting and overcome various barriers to implementation.  

This overall goal of the learning collaborative was to increase access to medication for opioid use disorder treatment through systems-level change. The specific objectives to promote this goal were: facilitate conversation and knowledge sharing, provide access to addiction treatment experts, assist in incorporation of evidence-based practice, and support efficient training.  

Based on meetings with FQHC leadership, CDPH divided the LC into two tracks: one for decision-makers (intended for behavioral health and medical leaders), and the other for providers working directly with patients receiving MOUD. This application focuses on the novel decision-maker track. This track was led by CDPH's Medical Director of Behavioral Health, a paid consultant, and a Director of Behavioral Health at a local FQHC. 

Each track consisted of quarterly, half-day in-person meetings from July 2017—June 2018. Decision-maker sessions combined presentations (e.g., members presenting on their systems' workflows) and small-group discussions (e.g. groups with the same electronic health record system sharing tracking metrics). Provider sessions consisted of didactic presentations, case studies, and small group discussions. Topics were selected from electronic surveys distributed after each session, creating an evolving, participant-driven process.  If a topic was not chosen, but received many votes, typically organizers still brought it up or sent an email, so that those who had questions about that topic could have them answered or connect with others who had faced similar issues. A large benefit of the LC, according to decision-makers, was the ability to meet and discuss with other decision-makers going through similar processes. These connections forged have continued to provide them with support and resources, even after the yearlong collaborative ended.  

For the decision-maker track, each participant completed homework” prior to each session to guide discussions (e.g., list existing metrics and what you would like to measure).  The four decision-maker track sessions focused on:

  1. Office-based opioid treatment workflows and goal-setting
  2. Clinical workflows, staffing patterns, and staff training
  3. Balancing harm reduction, diversion risk and state licensing requirements
  4. Office-based opioid treatment quality assurance and outcomes metrics

The original participants were from FQHCs who received HRSA funding to expand programs to treat opioid use disorder. Other health systems heard about it, asked to join, and were welcome. 

Costs associated with this practice included a consultant ($2500 per meeting) and space rental and catering ($600-700 per meeting). The provider track had continuing education credits and associated costs, but the decision-maker track did not.  

In order to work towards increasing access and capacity for medication for opioid use disorder in office-based settings, the objectives of the LC were: to facilitate conversation and knowledge sharing, to provide access to addiction treatment experts, to assist in incorporation of evidence-based practice, and to support efficient training. In spring 2017, health systems shared information about baseline service capacity, including number of prescribers with a DATA waiver, number of providers actively prescribing, number of patients receiving buprenorphine, and presence of various workflows and protocols.  The same systems-level metrics were again collected at the final decision-maker session (spring 2018). This allowed us to evaluate the extent to which the overall goal of increasing access and capacity was met. After each session, individual participants completed online evaluations of session format, presentations, and preferred topics for the next meeting (see standard evaluation questionnaire in appendix). The final individual evaluation, conducted after both tracks concluded, included in-depth questions about the overall utility of the LC. This allowed us to evaluate the extent to which each objective was met. 

Fifteen separate health systems participated in the LC decision-maker track: 11 were invited, and four asked to join after it was already in progress. Systems included 12 FQHCs, two hospital systems, and one community mental health program. There were 38 unique participants with an average of 21 attendees per decision-maker track session.  

The evaluations completed after each meeting helped plan the next meeting, from logistics (questions were asked about timing preference, balance between small group and large group discussion, etc.) to topic choice. This evaluation also indicated that attendees were finding them useful and intended to return. 

Health systems-level metrics were compared pre- and post-LC from the 11 health systems that participated for the entire year. Two health systems had not begun prescribing buprenorphine when the LC concluded, so they showed no change in active prescribing or number of patients. All other clinics showed increases in the number of providers actively prescribing buprenorphine, the number of active patients receiving buprenorphine, and the number of locations prescribing buprenorphine. In total, across all 11 health systems, there was a 52% increase in the number of prescribers with DATA waivers (from 79 to 120), an 84% increase in the number of providers prescribing buprenorphine (25 to 46), and a 68% increase in the number of locations prescribing buprenorphine (25 to 42).  

Sixteen decision-makers (42% of decision-makers) completed the final post-decision-maker LC track evaluation. These respondents strongly agreed (3.9 on 4-point scale) that their organization benefited from their attendance. Every respondent agreed or strongly agreed that the collaborative impacted their work and they would return if the collaborative were continued.  

The stated goal of this learning collaborative was to increase community capacity for buprenorphine in office-based settings. This evaluation demonstrates clear and substantial progress toward this goal, with substantial increases in staffing capacity and number of patients receiving buprenorphine. The LC also supported implementation of improved policies and workflows in multiple health systems.

Two of the four health systems that joined the LC after it had begun had not initiated buprenorphine prescribing and did not have designated funding to build these services. In addition, participants from these systems had limited knowledge of office-based opioid treatment infrastructure, requested prescriptive direction to build their programs, and were not able to engage in participant-selected discussions about complex topics. Nonetheless, they reported finding the meetings useful and stated that they valued guidance from the more advanced health systems.

Based on the evaluation of the LC, we recommend implementing two versions of the LC (1.0 for systems developing programs, and 2.0 for programs already providing services to build capacity, with alternating in-person and remote meetings).  We also recommend specific criteria for the individuals attending the decision-maker track.  Several health systems sent staff without decision-making authority; this made implementing new policies and securing administration involvement challenging. 

Given that some health systems had already committed to expanding access as a part of a separate grant, the documented increases in capacity cannot be attributed solely to participation in the LC.  Similarly, since most health systems sent staff to both the decision-maker track and the provider track, it is not possible to measure each track's unique impact.

Much focus nationally has been on increasing the number of waivered providers, with minimal focus on how to support the systems in which the providers work.  Identifying ways to provide systems support for providers is both valuable and necessary.   Many waivered prescribers named lack of system support as the primary reason for lack of buprenorphine prescribing.  Jurisdictions with multiple interested health systems may wish to implement or adapt this novel two-track LC model to help close this gap, particularly given participants response to in-person collaboration with their colleagues at other health systems. 

Unfortunately, due to staffing turnover and funding ending, CDPH was not able to continue to sustain this practice, even though most participants indicated they would continue attending. Fortunately, the connections made at the LC will continue to offer support and guidance for health systems providing buprenorphine in the City of Chicago. Specifically, building this program through partner input and creating each meeting based on participant-selected topics, led to unique, dynamic discussions. Creating a multidimensional educational experience where participants are never being talked AT, but always engaging with the topic, fostered a group of decision-makers ready to create and change and utilize their network. We also are applying the lessons learned and offering guidance to others who may be interested in hosting their own learning collaborative, either for community-based or hospital-based opioid use disorder treatment.  


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